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    My mentor on placement has told me I'm so far very good hands on and great with my patients.....however my documentation lacks. I completely lack confidence in this area. Infact when I'm asked to do any care plans, note writing anything that involves pen and paper I just feel dread wash over me. I cannot rely on my own judgement therefore I just do not know what to write. He's given me tips for example you can never write too much but I still can't grasp it. I don't know if it's because I'm really not the best writer. I also lack confidence in expressing what I think may be best in the fear of looking stupid I guess. Will this come over time? X


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    (Original post by wbnurse)
    My mentor on placement has told me I'm so far very good hands on and great with my patients.....however my documentation lacks. I completely lack confidence in this area. Infact when I'm asked to do any care plans, note writing anything that involves pen and paper I just feel dread wash over me. I cannot rely on my own judgement therefore I just do not know what to write. He's given me tips for example you can never write too much but I still can't grasp it. I don't know if it's because I'm really not the best writer. I also lack confidence in expressing what I think may be best in the fear of looking stupid I guess. Will this come over time? X


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    What year are you in? It definitely becomes easier as you go through the course and gain confidence and skills.
    Read books on care planning. Roper logan and Tierney is still widely used and a great tool for writing care plans.
    If you think about it from your own perspective, ie someone was to write about you. What would you like them to know? What would be important? Try and then and reverse that and see what is important to your patient. What would make their care person centred?
    Try and write as many care plans as you can. It will get better and easier as you develop yourself and are able to see how you're doing.
    There is no definite right or wrong I believe with care planning as a care plan can be pages and pages long. Just try to include what you can. For example, if the person was non verbal, what would you need to include that the person could not verbally tell you?
    So then you would look at how they communicate, how staff can assist in this. What are their likes and dislikes in routines etc? Any other sensory impairment?
    Then you can write what they would like to tell staff.
    I always write care plans in the first person. I believe it makes it easier as it ensures you always have that individual in mind. It ensures when others are reading it they're thinking of the person and hopefully visualising them. It is ultimately their documentation and if they could write their own, they may want to. But as it's our responsibility, we need to. Sit down with the patient. Get to know them. Ask them what they would like others to know.
    It will get easier!

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    How people document and the quality of documentation is so variable, not just from individual to individual, but between departments. It's a good idea to check whether a department has set ways of writing, also check your trust's guidance on documentation.

    Read other people's notes, see how they document and see if there's a way that you like and use that as a framework for how you do your writing. get stuck in and start doing more documentation, in the end, your mentor has to counter sign anything so if you've missed anything they'll point out where you've gone wrong.
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    Ditto Moonkatt's advice. Aim to write a minimum of twice a shift - once at the start with an initial assessment and plan of care, and once at the end with a summary of the shift, at the very least. I often write 3 times of more on day shifts where there are more changes to care. Our notes include a pre-printed circle sheet for our A-E assessment, but you may find yourself having to document a quick A-E down. I write stock phrases such as "Care taken over at", "Introduced self to parent/patient", "Safety checks completed" etc. I also like to write a 'nursing plan'. E.g. "4 hourly obs, on demand feeding, strict input/out, barrier nursed, administer medicines as prescribed, contact Drs if pyrexial again as ?for IVABx".

    As for the way you write, be concise. E.g. don't write "I went in to do Mr Smith's observations at 1400 and his respiratory rate was 35, his sats were 88 and he had increased work of breathing. His heart rate was 140 and he looked clammy so I put some oxygen on him and quickly went to tell the nurse I was working with who asked me to bleep the doctor".You can just write "Observations for 1400 as charted. EWS of 6. Oxygen via facemask administered initially. SN Jones made aware immediately, Drs bleeped". Your notes don't have to be written in beautifully structured sentences, it can literally be a series of bullet points as long as it contains all the information required. You also don't need to write out things like a whole list of what they've eaten for lunch as this should already be on the fluid chart - you could just put "Good oral intake as charted".

    Also, imagine that you what you have written is being read out in court - sounds dramatic to say that, but it's always possible it could happen. Is what you're writing professional? Is it non-judgemental? So rather than saying "I can't believe that Mr Thompson still hasn't got control of his diabetes, I've tried and tried to explain it to him but he just doesn't get it" you could say "Mr Thompson appears to be struggling to understand and control his diabetes. Basic education provided by ward nurses, diabetes nursing team contacted - attending ward this afternoon to see Mr Thompson". If the former was read out in court, it wouldn't sound professional and therefore wouldn't be of credit. This is perhaps an exaggerated example, but you get my drift.

    I hope this helps. You'll get there
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    It is great that you have been given clear feedback on your development areas. And the fact that you agree with your mentor that report writing is a development area is a great start.

    Loads of practice will certainly help, but a good starting point is to read as many notes as you can to see the various writing styles that are in use. Ask your mentor for good examples of notes to study. Ask your mentor to go through your notes and take their advice on what looks good and what can be improved.

    You will only learn by doing it. Do you know the phrase 'eat the toad'? This is your toad. Get stuck in and overcome your worries. Just think how nice it will feel when you have confidence in this. Let us know how you get on.
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    Thankyou so much guys fab words of wisdom. I do need to just bite the bullet and step out of my comfort zone and just do it! I think 90% of it is down to the fact I do not at all trust my own judgement. I do need to cut myself some slack I suppose I am only first year first placement but I just want to build my confidence! I look at what other nurses have written and a lot of the time it's opposite to what my mentor has advised (eg wound appears to be healing) well he said no no no never ASSUME! Because when it's read in court theyl question why you didn't find a definite answer etc. I'm hoping as my training goes on Itl become second nature.......it has to since most of what we do is paperwork!! Xx


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    (Original post by wbnurse)
    Thankyou so much guys fab words of wisdom. I do need to just bite the bullet and step out of my comfort zone and just do it! I think 90% of it is down to the fact I do not at all trust my own judgement. I do need to cut myself some slack I suppose I am only first year first placement but I just want to build my confidence! I look at what other nurses have written and a lot of the time it's opposite to what my mentor has advised (eg wound appears to be healing) well he said no no no never ASSUME! Because when it's read in court theyl question why you didn't find a definite answer etc. I'm hoping as my training goes on Itl become second nature.......it has to since most of what we do is paperwork!! Xx


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    Your mentor is correct.

    "The wound appears to be healing" is vague and tells the person reading it very little

    describe the wound, is it sloughy, is it granulating, etc, what is the surrounding skin like, compare it to previous records of dressing changes, is there exudate, if there is what is it like etc.

    It all comes with practice
 
 
 
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